This pathway has been produced by representatives from both primary and secondary care to support the management of dermatological conditions. These guidelines accompany the publication of new referral criteria from GHFT. The pathway is based on both PCDS guidance on the management of dermatological conditions, GHFT guidelines and the current CCG commissioning policies and supports the local guidance agreed by experts throughout the healthcare system.

Melasma Care Pathway Overview

Melasma is a chronic skin disorder that results in symmetrical, blotchy, brownish facial pigmentation. It can lead to considerable embarrassment and distress. Increased levels of melanin are found in affected skin.

This form of facial pigmentation is sometimes called chloasma, but as this means green skin, the term melasma (brown skin) is preferred.

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Presentation

Predominantly affects skin types III and IV

More common in females

Symmetrical involvement, most commonly of the centrofacial, malar and mandibular regions. The forearms can also be affected.

Light to dark brown patches - if the excess melanin is in the epidermis the patches are brown and more well-defined, whereas, if the excess melanin is in the dermis the patches are more grey-brown with less well-defined margins. Mixed types occur. A Wood's light may be helpful as it will enhance the colour if the pigment is mainly epidermal (e.g. some cases of melasma, and post-inflammatory hyperpigmentation), but not if the pigment is in the dermis. Epidermal melasma is more likely to respond to treatment

Red Flags

An asymmetrically pigmented facial lesion in an older person may be a lentigo maligna, but this should be quite easy to distinguish from melisma clinically.

There is accentuation of normally high pigmentation areas such as the areolae, axillae, genital skin and umbilicus

Investigations

Low serum sodium and raised serum potassium

Serum urea and albumin are raised because of dehydration

Serum cortisol level taken ideally between 8-9 am (random measurements have a low sensitivity for Addison's disease due to the pulsatile nature and diurnal variation of cortisol secretion). If the level of serum cortisol is:

< 100 nanomol/L - adrenal insufficiency is highly likely (if the patient is not on oral or inhaled steroids)

400 nanomol/L - adrenal insufficiency is unlikely (diagnosis not excluded if the patient is acutely unwell at the time since cortisol values may increase during illness)

Between 100 and 400 nanomol/L - refer to a specialist for further investigations eg synacthen test

Systemic features

Haemochromatosis results in diabetes, cirrhosis and cardiac failure

Hyperpigmentation

Slate grey or brown-bronze with a predominance for the face and other UV-exposed sites

Investigations

Iron levels - most people with haemochromatosis have elevated levels of iron in the blood

Transferrin saturation - transferrin is a protein that binds iron and transports it between the tissues. This test is one of the most sensitive tests for detecting early haemochromatosis. A transferrin saturation greater than 45% should be investigated further

Ferritin levels - ferritin is a protein that reflects the body's iron stores. Blood ferritin levels increase when the body's iron stores increase; however, levels of ferritin usually do not rise until iron stores are high. Therefore, ferritin levels may be normal early in the course of haemochromatosis. Ferritin levels greater than 400 ng/mL support a diagnosis of haemochromatosis, however, ferritin levels can also be increased in other conditions

PIH refers to darkening of the skin that occurs after an inflammatory eruption such as acne, eczema, lupus or following cutaneous injury. There may be a history of itch and / or signs of active skin disease such as erythema and scale. On occasions the skin can become hypopigmented

As with many of the causes of facial hyperpigmentation, the incidence and severity of PIH is much greater in patients of a darker skin colour

Management

Treatment is of the primary disorder - the patient will develop less postinflammatory hyperpigmentation if the skin condition is treated promptly and effectively

As with other causes of facial hyperpigmentation it is important to consider the possibility of contact allergic dermatitis or a photocontact allergic dermatitis, referred to as Riehl melanosis. Affected individuals usually have pruritus with mild erythema and scale. Patients should be referred for patch testing and sometimes photopatch testing

Once the hyperpigmentation has developed the time taken for the affected skin colour to lighten is highly variable and can take several years

Several medications can cause hyperpigmentation including the phenothiazines (especially chlorpromazine), minocycline, phenytoin, antimalarial drugs eg chloroquine and hydroxychloroquine, busulfan and other cytotoxic drugs, amiodarone, anti-retroviral drugs and tricyclic anti-depressants (especially imipramine) - the colour change seen is likely to have a grey tone

After discontinuing the drug it can take many months, sometimes years, for symptoms to improve

Poikiloderma refers to skin changes with thinning, increased pigmentation and dilation of the small blood vessels (telangiectasia)

In POC the skin is red-brown with prominent hair follicles, affecting the neck and lateral cheeks, characteristically with sparing of the shaded area under the chin

The cause is unknown, however, there is an association with UV exposure and it is more common in patients with fair skin. An additional theory is the photosensitising components of cosmetics and toiletries especially perfumes, although many doubt this link

AN is a skin condition characterised by darkening, thickening and hyperpigmentation of the skin, occurring mainly in the folds of the skin in the axilla, groin and back of the neck. The face and other sites can be affected

Most cases of AN are related to insulin resistance. Rarely is it associated with underlying malignancy, such patients have much more extensive skin thickening including of the palms and soles

Initial Primary Care Management

National Guidance

Generally a combination of the following measures is helpful.

Provide a patient information leaflet

Patients should use year-round UV protection:

Use broad-spectrum, visible light blocking, very high protection factor sunscreen of reflectant type and apply it to the whole face every day. Patients should reapply every two hours if outdoors during the summer months. Alternatively, or as well, use a make-up that contains sunscreen. Wear a broad-brimmed hat

Hormonal contraceptives:

consider changing to an alternative form of contraception if symptoms started / got significantly worse after the hormonal contraception was commenced

Skin camouflage

(a type of makeup which is not easily rubbed off, and can stay on when swimming, etc.) can be accessed via changing faces. Patients can self-refer, and volunteers run regular clinics all over the country, to help patients find the exact match for their skin. The make-up can then be prescribed on FP10.

Many topical treatments such as azelaic acid and topical retinoids have been tried, however, these are only likely to benefit a small number of patients. Currently, the most successful formulation is Pigmanorm cream, which is a combination of Hydroquinone, Tretinoin and Hydrocortisone.Pigmanorm cream is applied thinly once a day for an average of seven weeks, although if no improvement is noted after three months the treatment should be discontinued.Common adverse effects include erythema and scaling.The use of Pigmanorm cream has been found to result in improvement in up to 60-80% of those treated, and about 30% will achieve complete clearance, however, it can only be prescribed on a private basis. Pigmanorm should only be prescribed by a clinician experienced in treating melasma or using the drug.

Stronger chemical peels containing glycolic acid or trichloroacetic acid can be applied by those skilled in treating melasma (usually a dermatologist, always only in the private sector), however, they can provoke considerable inflammation

Some patients may benefit from a Fraxel laser, although evidence for this treatment is limited and it is only available privately

Most treatments are only available on a private basis

Treatment may not be successful

The stronger chemical peels, and in some cases Pigmanorm, can result in post-inflammatory hyperpigmentation (or occasionally hypopigmentation), which may be more obvious than the melasma

Even in those that get a good result from treatment, pigmentation will often reappear on further exposure to sun over the coming years

Guidance from GHFT

Patients with melasma should use high protection factor sunblocks and may benefit from the use of topical Hydroquinone containing products. There are several OTC products available and include Fade-Out which contains Kojic acid and is available from Boots. Other treatments includes acne preparations such as Retin-A and Skinoren. Treatment is often unsatisfactory and the condition tends to recur each summer.

Hydroquinone should not be used on patients with dark skins.

When to Refer

The only reason to refer is in cases of diagnostic doubt. A photograph sent via the Advice and Guidance Service is often all that is required to make the diagnosis.

Secondary Care Management

Melasma is not managed in secondary care and all referrals will be returned to the referring GP.

Reason for Pathway Selection

This pathway has been produced by representatives from both primary and secondary care to support the management of dermatological conditions. These guidelines accompany the publication of new referral criteria from GHFT. The pathway is based on both PCDS guidance on the management of dermatological conditions, GHFT guidelines and the current CCG commissioning policies and supports the local guidance agreed by experts throughout the healthcare system.